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Home > Professional Reference > Abnormal Cervical Smear Results

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Abnormal Cervical Smear Results

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

See related Cervical screening article and the Cervical cancer article.

Screening started in 1987, and since 2003 screening has been performed using liquid-based cytology (LBC). Meta-analyses have shown LBC to have higher sensitivity, equal specificity and lower rates of inadequate samples.1 The percentage of inadequate samples fell substantially from consistently over 9% since recording started in 1998 to 2.8% in 2009-2010.2

Standard recall schedule

  • First invitation for screening at age 25 in England (20 in rest of UK).3 There is no evidence that screening women aged 22-24 reduces the incidence of cervical cancer at ages 25-29.4
  • Routine recall:
    • England: routine 3-yearly recall between ages 25-49, then 5-yearly recall until aged 65.
    • Scotland: routine 3-yearly recall from age 20 until aged 60.
    • Wales: routine 3-yearly recall from age 20 until aged 65.
    • Northern Ireland: 5-year recall from age 20 until aged 65 (many GPs run their own recall at an interval of three years).
  • Consider offering a smear to patients above the upper age limit who have not been screened since age 50 or have had recent abnormal tests.

Dyskaryosis on cervical smear

Management of cervical smear results5

Result

Action

Negative
  • Investigate and manage incidental findings (e.g. infections).
  • Ensure that the patient is informed of the result.
  • Recall as appropriate for a negative result.
Inadequate
  • Repeat sample immediately after treating any infection or atrophy, preferably within three months.
  • Repeat sample as soon as convenient if technically inadequate.
  • If persistent (three inadequate samples), advise assessment by colposcopy.5
Borderline
  • Borderline nuclear change in endocervical cells - refer for colposcopy.
  • Borderline nuclear change in squamous cells:
    • Treat any associated condition and repeat the screen at no more than six months (particularly important where there is an association with human papillomavirus (HPV). The majority of smears will return to normal by this stage.
    • Refer for colposcopy if there are three smears in a series reported as borderline nuclear change in squamous cells) without the woman being returned to routine recall, or three borderline or more severe results in a 10-year period.
    • Three consecutive negative results, six months apart, are required before returning to routine recall.
    • Repeat sample in three to six months when the differential diagnosis is between benign/reactive changes and higher
      degrees of dyskaryosis or possible glandular neoplasia.
    • The laboratory may recommend a repeat screening in a shorter interval, or that gynaecological referral should be considered.
Mild dyskaryosis
  • Ideally, women should be referred for colposcopy after one mild dyskaryotic smear, but it remains acceptable to recommend a repeat test within six months - many will have returned to normal by this stage.5
  • Always refer for colposcopy after two tests reported as mild dyskaryosis without a return to routine recall.
  • Three consecutive negative results, six months apart, are required before returning to routine recall.
  • If a single mild dyskaryotic result is obtained after treatment for carcinoma in situ stage 2 or worse, refer for colposcopy.
  • If, in a 10-year period, there are three borderline or more severe results, refer to colposcopy.
Moderate dyskaryosisRefer for colposcopy.
Severe dyskaryosisRefer for colposcopy.

Other results

  • Inflammatory changes usually indicate infection:3
    • Mild inflammation
    • Moderate inflammation
    • Severe inflammation
  • High-risk human papillomavirus (HPV) types (16, 18, 31, 33) have been found to be present in close to 100% of all cervical cancers:
    • Research has indicated that women with a mild or borderline smear result, who have no evidence of high-risk HPV infection are very unlikely to develop cervical cancer.5
    • HPV testing is not currently recommended for primary screening, but this may change.67
  • Actinomyces: a smear may show actinomyces-like organisms (ALOs), especially if an intrauterine contraceptive device (IUCD) is in situ; however, unless there is clinical evidence of pelvic inflammatory disease, they are of no significance.
  • Candida: many treatments are available including topical or oral imidazoles.
  • Gardnerella: treatment is metronidazole 400-500 mg twice daily for seven days.
  • Herpes: antiviral therapy is effective in both initial attacks and recurrences. The licensed drugs are aciclovir, valaciclovir and famciclovir. Oral therapy is required. Topical treatment is inadequate. There is no benefit in combining topical and oral therapy.
  • Koilocytosis: this is the presence of koilocytes (cells infected by HPV). They typically have shrivelled nuclei with a halo.8 They have a low prognostic value for cervical intraepithelial neoplasia (CIN).9
  • Trichomonas: metronidazole is the treatment of choice.
  • Viral inflammation unspecified.

Document references

  1. Cervical cancer - cervical screening, NICE Technology Appraisal (Oct 2003); Liquid-based cytology for cervical screening (review)
  2. Cervical Screening Programme 2009-2010, Information Centre 2010
  3. NHS Cervical Screening Website
  4. Sasieni P, Castanon A, Cuzick J; Effectiveness of cervical screening with age: population based case-control study BMJ. 2009 Jul 28;339:b2968. doi: 10.1136/bmj.b2968. [abstract]
  5. Colposcopy and Programme Management: Guidelines for the NHS Cervical Screening Programme, NHS Cancer Screening Programme (2010)
  6. Ronco G, Giorgi-Rossi P, Carozzi F, et al; Efficacy of human papillomavirus testing for the detection of invasive cervical Lancet Oncol. 2010 Mar;11(3):249-57. Epub 2010 Jan 18. [abstract]
  7. Gravitt PE, Belinson JL, Salmeron J, et al; Looking ahead: A case for HPV testing of self-sampled vaginal specimens as a Int J Cancer. 2011 Feb 3. doi: 10.1002/ijc.25974. [abstract]
  8. Koilocytes, PathGuy; Photo
  9. Kruse AJ, Baak JP, Helliesen T, et al; Prognostic value and reproducibility of koilocytosis in cervical intraepithelial neoplasia. Int J Gynecol Pathol. 2003 Jul;22(3):236-9. [abstract]

Internet and further reading

Acknowledgements

EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2011.
Document ID: 4053
Document Version: 23
Document Reference: bgp25985
Last Updated: 8 Jun 2011
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